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新型冠狀病毒疫情系列之七 — 意大利疫情及供氧機

2020/3/24 — 15:43

意大利3月21日的一天內增加793宗死亡,迄今為止的因新型冠狀病毒的死亡人數躍升至4825,為全球總數的38.3%,當中三分之二集中在北部倫巴第區。

意大利政府從3月12日開始實施了全國性的封城措施,但疫情走勢未見平頂,其民防部負責人安傑洛.博雷利認為,有理由相信在未來的一周或兩周可以見到好轉跡象(註一),意大利疫情在其後兩天似有紓緩跡象。

網上不少流言,歸究於意大利北部的製衣業聘請了不少溫州人,但這個指責從未出現在較嚴肅的刊物上。根據維基資料,未計非法移民,中國人在意大利的人口約為32萬,只佔意大利人口的0.5%。其實,華人人口約佔全球人口的每七人佔一人,世界各地的中國人移民著實不少,意大利北部是否特別密集,有待考證。

廣告

3月13日《柳葉刀》期刊登了一篇文章,「新型冠狀病毒與意大利,下一步如何?」指出從模型估算,它們需要在未來一周內增加2千5百張病床,政府準備立法增加聘請2萬名醫生和增加5千個供氧機。缺乏供氧機和意大利人口極度老化,可能是其死亡率高的一個主因。文章指出死亡人口的83%超過60歲,90歲以上的佔14.1%。

也有論調指責政府在處理疫情時採取年齡主義手段,放棄老人。3月18日《新英倫》期刊的文章 『意大利疫情上的「醫療道德問題」』為醫療人員伸冤(註5),文章訪問了一位意大利北部的一位前線醫生,他懷疑自己受了感染,但因為測驗套件不足,而他的癥狀又不明顯,被勸諭回家自行隔離5天。5天後,他開始發燒,被確診感染。他指出,在給誰使用供氧機問題上,他們內心很難過。曾經有一位很健壯的80歲老人,因為排不上供氧機而缺氧至死。他們根據2019年的指引 (在病人太多時的處理方法) “Too Many Patients … A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation during Disasters”行事。他解釋,決定權在分診醫官手上,分診醫官根據分診算法決定先救誰,而這些又與病人的估算康復期相關。

廣告

供氧機對治療新型冠狀病毒病人十分重要,根據一篇3月9日刊登在《柳葉刀》期刊的文章(註6)指出,在191個病例中,生還者的平均出院期為22天,非生還者的平均死亡期為19天,而總數病人需要鼻管供氧治療的為21%;不入侵式供氧機為14%;入侵式供氧機為17%;機械肺的為3%。從資料看,該次案例可能缺乏供氧機。因為在死亡個案中,有98%出現呼吸困難,而只有約6成得到機械式供氧機。

香港目前不清楚有多少輔助呼吸的機器,但這些機器已在全球搶購,不能自行生產的地方,如香港,基本上沒有機會增添。英國國會討論過這問題,在3月16日國會辯論中,衛生事務大臣馬特.漢考克表示,供氧設備對處理今天的疫情是關鍵性的,首相已親自致電本國的主要生產商加速生產。(註7)

備註

註一

BREAKING: Italy reports almost 800 new coronavirus deaths as total approaches 5,000

註二

https://www.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6

註三

https://en.wikipedia.org/wiki/Chinese_people_in_Italy

註4

COVID-19 and Italy: what next?  March 13, 2020

We predict that if the exponential trend continues for the next few days, more than 2500 hospital beds for patients in intensive care units will be needed in only 1 week to treat ARDS caused by SARS-CoV-2-pneumonia in Italy. In the meantime, the government is preparing to pass legislation that will enable the health service to hire 20 000 more doctors and nurses and to provide 5000 more ventilators to Italian hospitals.

註5

Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line

註6

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

註7

https://hansard.parliament.uk/commons/2020-03-16/debates/235689EC-0A18-4488-BFCF-9F012A1A0C1B/Covid-19

The Secretary of State for Health and Social Care (Matt Hancock)

Thirdly, we are boosting the NHS. Ventilation is mission critical to treating the disease. We have been buying up ventilation equipment since the start of the crisis, but we need more. Today, the Prime Minister hosted a call with the nation’s advanced manufacturers asking them to join a national effort to produce the ventilators we need. We have set up a dedicated team to do that, and we are hugely encouraged by the scale of the response so far. Later today, the NHS will set out the very significant steps it is taking to prepare.

Fluke Biomedical

https://intensivecarehotline.com/ventilators-breathing-machines/

https://www.wisegeek.com/what-is-the-difference-between-a-respirator-and-a-ventilator.htm

全文完

https://www.nejm.org/doi/full/10.1056/NEJMp2005492?query=featured_home

Facing Covid-19 in Italy — Ethics, Logistics, and Therapeutics on the Epidemic’s Front Line

Explaining the recommendations’ rationale, Vergano described how difficult it was for the frail and elderly to survive the prolonged intubation required to recover from Covid-19–related pneumonia. As excruciating as it was to admit, about a week into the epidemic’s peak, it became clear that ventilating patients who were extremely unlikely to survive meant denying ventilatory support to many who could. Nevertheless, even under the direst circumstances, rationing is often better tolerated when done silently. Indeed, the ethical guidance was widely criticized. Committee members were accused of ageism, and critics suggested that the gravity of the situation had been exaggerated and that Covid-19 was no worse than influenza.

Though ethical dilemmas, by definition, have no right answer, if and when other health systems face similar rationing decisions, is societal backlash inevitable? To create an ethical framework for resource allocation reflecting society’s priorities, Lee Biddison, an intensivist at Johns Hopkins, led focus groups around Maryland to discuss community members’ preferences. The resultant document, published in 2019 and entitled “Too Many Patients … A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation during Disasters” — noting that “an influenza pandemic similar to that of 1918 would require ICU and mechanical ventilation capacity that is significantly greater than what is available” — emphasizes ethical principles similar to those of the Italian committee.3

Third, the triage algorithm should also be reviewed regularly as knowledge about the disease evolves. If we decided not to intubate patients with Covid-19 for longer than 10 days, for example, but then learned that these patients need 15 days to recover, we would need to change our algorithms.

We extracted data regarding 1099 patients with laboratory-confirmed Covid-19 from 552 hospitals in 30 provinces, autonomous regions, and municipalities in mainland China through January 29, 2020. The primary composite end point was admission to an intensive care unit (ICU), the use of mechanical ventilation, or death. RESULTS The median age of the patients was 47 years; 41.9% of the patients were female. The primary composite end point occurred in 67 patients (6.1%), including 5.0% who were admitted to the ICU, 2.3% who underwent invasive mechanical ventilation, and 1.4% who died. Only 1.9% of the patients had a history of direct contact with wildlife. Among nonresidents of Wuhan, 72.3% had contact with residents of Wuhan, including 31.3% who had visited the city. The most common symptoms were fever (43.8% on admission and 88.7% during hospitalization) and cough (67.8%). Diarrhea was uncommon (3.8%). The median incubation period was 4 days (interquartile range, 2 to 7). On admission, ground-glass opacity was the most common radiologic finding on chest computed tomography (CT) (56.4%). No radiographic or CT abnormality was found in 157 of 877 patients (17.9%) with nonsevere disease and in 5 of 173 patients (2.9%) with severe disease. Lymphocytopenia was present in 83.2% of the patients on admission.

The median time from illness onset (ie, before admission) to discharge was 22·0 days (IQR 18·0–25·0), whereas the median time to death was 18·5 days (15·0–22·0; table 2). 32 patients required invasive mechanical ventilation, of whom 31 (97%) died. The median time from illness onset to invasive mechanical ventilation was 14·5 days

https://www.thelancet.com/pb-assets/Lancet/pdfs/S014067362305663.pd

[16:33, 2020年3月17日] lausanching: Italy has had 12 462 confirmed cases according to the Istituto Superiore di Sanità as of March 11, and 827 deaths. Only China has recorded more deaths due to this COVID-19 outbreak. The mean age of those who died in Italy was 81 years and more than two-thirds of these patients had diabetes, cardiovascular diseases, or cancer, or were former smokers. It is therefore true that these patients had underlying health conditions, but it is also worth noting that they had acute respiratory distress syndrome (ARDS) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pneumonia, needed respiratory support, and would not have died otherwise. Of the patients who died, 42·2% were aged 80–89 years, 32·4% were aged 70–79 years, 8·4% were aged 60–69 years, and 2·8% were aged 50–59 years (those aged >90 years made up 14·1%). The male to female ratio is 80% to 20% with an older median age for women (83·4 years for women vs 79·9 years for men).

https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30627-9/fulltext

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